Provider Demographics
NPI:1437370798
Name:LAKE WYLIE FAMILY DENTISTRY PA
Entity Type:Organization
Organization Name:LAKE WYLIE FAMILY DENTISTRY PA
Other - Org Name:DR THOMAS N STALL DMD OR DR STACY L BLACKMON DDS
Other - Org Type:Other Name
Authorized Official - Title/Position:INSURANCE DEPT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:STALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-831-8856
Mailing Address - Street 1:PO BOX 5248
Mailing Address - Street 2:
Mailing Address - City:LAKE WYLIE
Mailing Address - State:SC
Mailing Address - Zip Code:29710
Mailing Address - Country:US
Mailing Address - Phone:803-831-8856
Mailing Address - Fax:803-831-8966
Practice Address - Street 1:1100 VILLAGE HARBOR DR
Practice Address - Street 2:
Practice Address - City:LAKE WYLIE
Practice Address - State:SC
Practice Address - Zip Code:29710
Practice Address - Country:US
Practice Address - Phone:803-831-8856
Practice Address - Fax:803-831-8966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2830122300000X
SC3673122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty